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• Patients with true neurologic TOS caused by congenital anomalies (fibromuscular bands) that cause compression of the brachial plexus. Surgery is done to relieve the compression by resecting the first rib and all anomalous fibromuscular tissue around the brachial plexus and subclavian vessels.

• Patients who are experiencing progressive sensory loss or muscle wasting

• Patients with fractures of the clavicle who develop excessive callus formation that causes compression of the brachial plexus

• In rare cases, breast reduction surgery has been recommended for women with extremely large breasts (hypertrophy) to relieve the excess weight load to the anterior chest wall.

Types of Surgical Procedures

There are several types of surgical procedures for the treatment of TOS including:

• Transaxillary First Rib Resection - This involves surgical resection of the first rib using a transaxillary approach (incision is made under the armpit to gain access to the first rib. It is recommended for lower TOS involving C8-T1 nerve root symptoms. The most common complication is paresthesia with reduced sensation along the upper arm. Rare complications include injury to the brachial plexus and pneumothorax (punctured lung).

• Cervical Scalenectomy - This surgical procedure involves severing the scalene muscle at the point of attachment to the first rib. It is recommended for upper TOS involving C5-C7 nerve root symptoms. Complications may include:

  • neck hematoma (a collection of blood)
  • chylus drainage (leakage of a fluid that is usually drained through the lymphatic system)
  • Horner's syndrome (injury to the nerves of the neck resulting in a constricted pupil and drooping eyelid involving one side of the face)

• Resection of Fibrous Bands - This surgical procedure involves surgically removing bands of fibrous tissue in the costoclavicular region.

Although results of surgery for TOS may vary from patient to patient, an overall improvement of about 70% has been reported with a follow-up of 3-5 years in patients with true neurologic TOS following first rib resection or scalenectomy (Orthop. Clin. North America, Vol. 27(2):265-303, April 1996).

Postsurgical recurrence of TOS after rib resection is estimated at 2-30% of patients, typically secondary to significant scarring. The best outcome is typically in patients with occupations not requiring labor while the worst outcome is in obese patients and patients with other nerve entrapments in affected arm.

Recuperation Following Surgery

Within a short time after surgery, the patient commences range-of-motion exercises for the shoulder and cervical spine under the direction of a physical therapist. The patient typically achieves full range of motion within 3-4 weeks and then may begin muscle strengthening exercises. The surgery does not correct muscle imbalance which may have developed due to improper posture so strengthening and stretching these affected muscles is part of the postoperative treatment plan.

Regarding the long term results of surgery for treatment of thoracic outlet syndrome, some studies reported that 90% of patients who underwent surgery had good results and 65% of these patients maintained the benefit of surgery after 15 years. However, another study followed patients diagnosed with TOS who either elected to undergo surgery or were treated with conservative measures. The data indicated that return to work and symptoms severity were not significantly different between the two groups.